Provider Demographics
NPI:1275065047
Name:BOOSAHDA, STEPHANIE ELLEN (LPN)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:ELLEN
Last Name:BOOSAHDA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:654 WILLOW ST
Mailing Address - Street 2:BASS RIVER
Mailing Address - City:SOUTH YARMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02664-5636
Mailing Address - Country:US
Mailing Address - Phone:508-360-6227
Mailing Address - Fax:
Practice Address - Street 1:654 WILLOW ST
Practice Address - Street 2:BASS RIVER
Practice Address - City:SOUTH YARMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02664-5636
Practice Address - Country:US
Practice Address - Phone:508-360-6227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-31
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALPN57523164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALPN57523OtherMASSACHUSETTS BOARD OF NURSING